ORANGE COUNTY UROLOGY ASSOCIATES INC A …

1 ORANGE COUNTY UROLOGY ASSOCIATES , INC. A M e d i c a l G r o u p Paul A. Brower, Don Bui, Jennifer Gruenenfelder, Tammy S. Ho, Moses M. Kim, James P. Meaglia, Leah Y. Nakamura, Josh M. Randall, Karan J. Singh, Aaron Spitz, Daniel Su, Neyssan Tebyani, Name: _____ Birth Date: _____ Last First MI Sex: (circle one) M F Social Security #_____ Drivers License#_____ Address_____ City_____ State_____ Zip_____ Home # _____Cell # _____ Work # _____ E-mail Address _____Preferred means of communication (circle one) Cell Phone Home Phone Email USPS Mail Any NonePrimary Physician_____ Employer _____ Referring Physician_____ Occupation _____ Marital Status (Circle one) S M D W Pharmacy Name_____ Spouse s Name_____ Phone # _____ Spouse Phone#_____ Pharmacy (Street, City) _____ Emergency Contact (other than spouse) _____ Relationship to you_____ Phone # _____ Race (circle one) African-American/Black Asian Asian/Pacific Islander Chinese Korean Native Hawaiian Native American/Alaskan Native Vietnamese White Other_____ Decline to State Ethnicity (circle one) Hispanic/Latino Non-Hispanic/Non-Latino Language Choice (circle one)

2 English Spanish Chinese Tagalog Vietnamese Korean Farsi Other_____ RESPONSIBLE PARTY If other than self or you are a minor. Name: _____ Relationship:_____ Address_____ City_____ State_____ Zip_____ Home #_____ Work #_____ #_____ MEDICAL INSURANCE (please present insurance cards for us to photocopy) Primary Insurance Company: _____ Subscriber s Name_____ Subscriber s Relationship to Patient _____ Insured s ID#_____ Group #_____ Medicare #_____ Secondary Insurance Company: _____ Subscriber s Name_____ Subscriber s Relationship to Patient_____ Insured s ID#_____ Group #_____ Medicare #_____ _____ PLEASE BE ADVISED THAT YOU WILL RECEIVE SEPARATE BILLS FOR ANY LAB TESTS, X-RAYS, ETC. THAT MAY BE ORDERED FOR YOU, AS THEY ARE DONE BY AN OUTSIDE SOURCE. Assignment of Benefit-Financial Agreement Assignment and Release. I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT THEY ARE COVERED BY MY INSURANCE.

3 I hereby assign my benefits to be paid directly to my physician and any assisting physicians. I understand a monthly service fee will be charged on all balance 61 days and older. In the event of default, I agree to pay all costs of collection and reasonable attorney s fees. I authorize this provider to release any information required to process this claim to my insurance company. Date:_____ Your Signature X_____ THANK YOU FOR YOUR CAREFUL COMPLETION OF THIS IMPORTANT FORM Revised 8/22/14 ORANGE COUNTY UROLOGY ASSOCIATES , INC. A M e d i c a l G r o u p Revised 8/22/14 PF-2000 Acknowledgement of Receipt of Notice of Patient Privacy ORANGE COUNTY UROLOGY ASSOCIATES , Inc. reserves the right to modify the privacy practices outlined in the notice. I have received a copy of the Notice of Privacy Practice of ORANGE COUNTY UROLOGY ASSOCIATES , Inc.

4 _____ _____ Signature of Patient Name of Patient (Please Print) _____ _____ Date Patient Date of Birth Preferred/Secure Phone Options: Yes No If yes, Please provide a phone number in which we may leave a message on your voicemail with your personal health information. Home Cell Work Phone#:_____ Authorized Email Address: To facilitate communication between OCUA and our patients, I give permission to use my email address in a secure online environment. The email communication will be through secure, encrypted messaging. I understand the email address I provide will be used primarily for accessing my patient portal on the OCUA website at It will also be used to contact me for future appointment reminders. Unless I inform OCUA that my email address has changed, OCUA has permission to use the email address below. OCUA will not share this address with any other entity. Email Address: (Please print clearly) _____ Expanded Medical Release Option: *Please note: This is Valid for 1 Year* Please list any person(s) you would like to authorize to have access to your billing, appointments or health information.

5 ** Such as a Spouse, Parents, Family Members, and/or Friends. ** With the exclusion of information that is protected under State or Federal law Name Relationship _____ _____ _____ _____ Signature of Patient/Representative Relationship of Patient Representative ** Please note that State Federal law provides additional protections for minors and restricts the release of certain patient information to anyone other than the minor Revised 03/05/14 ORANGE COUNTY UROLOGY ASSOCIATES , Inc. Financial Policy Welcome to ORANGE COUNTY UROLOGY ASSOCIATES , Inc. Your initial visit can range from $200 to $500. Here are some guidelines to help you get your insurance information ready for your visit: MEDICARE Do you have a supplemental plan?

6 YES We will bill both insurances on your behalf. You will be billed for any balance owed by you after the insurances have paid their amounts. NO i. Have you met your deductible? If not; (2014: $147 Part B) ii. You will be required to pay your co-insurance percentage and any portion of the deductible that has not been met at check in. PPO PLAN You will be expected to pay your share of cost at check in. This will include any office services including drugs Are we contracted with your insurance company? YES You will be required to pay your co-payment and/or deductible at check in. NO You will be required to pay in full at check in. Do you have a SECONDARY INSURANCE? YES You will be required to pay your co-payment and co-insurance amounts at check in. We will bill your secondary insurance; if we receive payment we will reimburse you any excess amounts. You may receive charges from an outside laboratory.

7 These charges were incurred because the tests were necessary to diagnose and/or treat your condition. We will bill your insurance(s) as a courtesy. Payments received in excess of your account balance will be refunded to you. HMO, EPO, POS OR MANAGED CARE PLANS Has your primary care physician AUTHORIZED your visit? Visits with prior approval. If your plan requires a co-payment, you will be required to pay at check in. Visits without prior approval. You will be required to pay in full at check in. You will be required to PAY IN FULL at check in if; You are OUT OF NETWORK You have NO INSURANCE We are NOT CONTRACTED WITH YOUR INSURANCE **We recommend that you verify your benefits with your insurance plan prior to your visit.** IF YOU FAIL TO PROVIDE COMPLETE, UP-TO-DATE, ACCURATE INSURANCE INFORMATION You will be considered a CASH patient and will be required to pay in full at check in. OCUA will not be responsible for billing insurance for this date of service retroactively Effective May 1, 2009 the Federal Trade Commission (FTC) has implemented a new regulation known as the Red Flag Rule requiring physicians to develop and implement identity theft detection and prevention programs.

8 TO PROTECT YOU AGAINST IDENTITY THEFT we are required to ask for a photo ID, and a second type of identification. _____ I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY FOR ORANGE COUNTY UROLOGY ASSOCIATES , INC. _____ _____ _____ Print Name Signature Date Revised 03/05/14 Point of Service Option We understand you have the ability to use a Point of Service (POS) or HMO option. ORANGE COUNTY UROLOGY ASSOCIATES , Inc. holds contracts with several HMO groups. If we hold a contract it is best for you to take advantage of your HMO option, this will decrease your out of pocket expense. If you choose to use your POS option ORANGE COUNTY UROLOGY ASSOCIATES , Inc. will collect your entire out of pocket expenses. Please be aware if you choose the POS option your plan may not allow you to switch over to the HMO option for your future care. _____ _____ Print Name Sign Name _____ _____ OCUA Signature Date ** ORANGE COUNTY UROLOGY ASSOCIATES New Patient Information Form (Male) Rev Created on 8/22/2014 Name: Today s Date: Office Use Only Age: Date of Birth: Who referred you?

9 Date ROS by Present Illness In your own words, what medical problem or concern brings you to our office today? For how long? _____ Degree of Severity 0 1 2 3 4 5 6 7 8 9 10 Current Urinary Symptoms Incontinence (Involuntary Loss of Urine) Frequency of urination with urgency Number of voids during the day? _____ with cough or sneeze Number of voids during the night? _____ Number of pads used per day? _____ Urgency Blood in urine Number of voids during the day? _____ Pain in testicles Number of voids during the night? _____ Flank Pain Burning/ Painful urination Fevers/Chills Urethral discharge Prior Urological History Previous prostate surgery: _____ Urethral Stricture Medication to urinate better Kidney infections/pyelonephritis name of drug: _____ Kidney stones Elevated PSA Family history of kidney stones: Whom? _____ Prostate Inflammation/Prostatitis Hydrocele Prostate Cancer Other urinary tract disorder: _____ Family history of prostate cancer Sexual Dysfunction (impotence or ED) Whom?

10 _____ Infertility Enlarged Prostate Premature Ejaculation Bladder infections Previous Sexually Transmitted Disease s Please answer the following questions: Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always 1. How often do you urinate again less than 2 hours after a prior urination? 0 1 2 3 4 5 F Freq 2. How often do you find it difficult to postpone urination? 0 1 2 3 4 5 U Urge 3. How often do you have a weak urination stream? 0 1 2 3 4 5 Stream 4. How often do you push or strain to begin urination? 0 1 2 3 4 5 S Strain 5. How often do you find that you stop and start again when you urinate? 0 1 2 3 4 5 I Interm 6. How often do you have a sensation of not emptying your bladder after urination? 0 1 2 3 4 5 PVR 7. How many times do you typically get up to urinate when you go to bed at night? None 1 time 2 times 3 times 4 times 5 or more N Next TOTAL SCORE _____/35 Quality of Life due to urinary symptoms Delighted Pleased Mostly satisfied Mixed, equally satisfied and dissatisfied Mostly Dissatisfied Unhappy Terrible 8.